Near Misses, Close Calls, etc.

[Jamuhh]

I am starting a project at work to help improve reporting of near miss events.

I am trying to gather real-life examples of near misses. If you look through the interwebz, near miss is defined as an event that didn't reach the patient but could have had terrible consequences. I would also like to hear about events that reached the patient but didn't cause harm (you might call this risky behavior instead.)

I know it's hard to put yourself on the line and admit when you've had a near miss, so I'll give some examples of my own.

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*ibuprofen was prescribed and approved by pharmacy for a patient under 6 months (none was ever given to the patient)

*I wasted the wrong amount of a drug (didn't waste enough) but caught the mistake before administering

*I gave a med via PICC line w/o first flushing the previously running med; the two drugs were compatible but I was unaware of this and could have caused harm if they were not. (More of a risky or reckless behavior).

*We have pt cubbies for meds; both current and d/c'd patient prescribed the same nasal saline. The current pt dose had not arrived and d/c'd patient's dose was still in cubbie. I grabbed saline without looking at label and once in the room scanned the barcode to see that it did not belong to that patient. (Sure, it's just saline... but could have been something else.)

*I've taken CHG wipes to patient who is allergic as well as non-verbal but realized the mistake just before starting the wipe down

*The wrong weight was charted on a patient at admission. The physician prescribed a medication based on this incorrect weight, but the pharmacist reacted with There's no way a 14 year old kid weighs 5kg. Fix this weight!” (Imagine if the weight was more likely to be correct but was off significantly!)

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Thanks y'all! Let's get a dialogue going!

[anon456, BSN, RN]

I had an older teenaged patient who was prescribed the usual adult dose of Tylenol of 1000mg. If the patient had been a typical size for their age, this would have been fine. It turned out the patient was very, very small for their age due to some underlying chronic conditions and was more the size of an 8 year old. I told the doc and the order was changed to a weight-based dose.

[Stella.didnt.doit, BSN, RN]

I experienced a severe reaction to tylenol #3 after 2nd dose, next time I am prescribed pain medications i am given vicodin followed by an allergic reaction. Third MD gives me lortabs ( s/p car accident with lengthy recovery/therapy need-- pre my nursing career) and i have another reaction. Presents with chest pain several hours before actual hives. Double me over chest pain. later after becoming a nurse I was informed that I would therefore probably be allergic to all forms of 'codeine'

Many years later I have a deforming injury to my right hand needing medical attention. As I sit in triage (the hospital i worked at) I hear the nurses speaking about how they 'cant figure out how to enter my allergies' in the computer. I, while not alarmed, recognize how inappropriate and risky this situation is for our patients... but can obviously repeat this warning should need to.

Fast forward to my discharge instructions from arrogant nurse after getting nothing for pain and doc just yanks finger back in alignment. -She hands me a script for percocet. I tell her i will probably be allergic to this she tells me I am incorrect and I 'wont be gettin dilaudid' ... Seriously.

I leave but thankfully the Pharmacy has picked up on the risk I mentioned earlier. Though I did not tell him about my allergies, they were on record since Walgreens filled all of my previous meds and had this recorded.